Alcohol Detoxification Dr Julia Lewis GSSMS

Overview What is alcohol withdrawal? How is alcohol withdrawal treated? Importance of vitamins Details of Symptom Triggered Detoxification Gwent treatment agencies

The Alcohol Withdrawal Syndrome a question…. What experiences have you had of patients undergoing alcohol withdrawal/ detoxification?

Alcohol Withdrawal Develop 6-8 hours after last drink Maximal in first 24 hours Risk of seizures low after 48 hours Typically over by 5 days 6 Hrs 24 Hrs 48 Hrs 5 Days

Visual/ tactile hallucination Alcohol Withdrawal Symptoms: the slippery slope Anxiety Tremors Sweats Confusion Fever Tachycardia Visual/ tactile hallucination Seizures Death

Uncomfortable withdrawal Seizures / autonomic instability and death Alcohol Withdrawal Mild withdrawal Uncomfortable withdrawal DTs / Wernicke’s Seizures / autonomic instability and death

The brain likes the system to remain in balance Basic Neurobiology CNS contains balance of excitatory and inhibitory neurotransmitters Excitatory Inhibitory The brain likes the system to remain in balance

Cell Body Neurophysiology Insulation Insulation Vesicle containing inhibitory neurotransmitter Vesicle containing excitatory neurotransmitter Excitatory receptor Inhibitory receptor

GABAA Receptor Cl-

Kindling no alcohol full blown DT’s with hallucinations & delusions spontaneous seizures seizures anxiety, panic, agitation autonomic symptoms (sweating, tachycardia) shakes, tremors 5 10 15 17 19 21 23 25 no alcohol Estimated number of alcohol withdrawal episodes

Glutamate & GABA Glutamate excitatory GABA inhibitory

Neuro-adapation: Rabbits & Donkeys + glutamate - GABA

Neuro-adapation: Rabbits & Donkeys + glutamate - GABA

Neuro-adapation: Rabbits & Donkeys + glutamate - GABA

Neuro-adapation: Rabbits & Donkeys + glutamate - GABA

The Pesky Glutamate Glutamate has a neurotoxic effect (excitotoxicity) When glutamate builds up in the synaptic gap and the brain can’t clear it – it kills itself! Potential protective effect with acamprosate

How do we do alcohol detoxification?

Neuro-adapation: Rabbits & Donkeys So detox is: = Benzodiazepine

How might a patient feel coming in for a detox?

Pharmacological Management Alcohol Detoxification Pharmacological Management Supportive Nursing of equal importance Reality orientation Minimise stimulation, calm environment Nutrition & hydration

Pharmacotherapy Drugs with cross-tolerance with alcohol (reviewed by Williams and McBride, 1998) Benzodiazepines are preferred (diazepam, chlordiazepoxide)

Fixed Reduction Frequent small doses of a BZD tapering over a period of 5-7 days Problems: over medication under medication (kindling) drug seeking behaviour

Fixed Reduction: when it is useful Wards not trained to use Front-Loading In special groups where hepatic function is reduced and shorter acting benzodiazepines are required (e.g. the elderly, hepatic impairment) What are the shorter acting benzodiazepines? – oxazepam, lorazepam

Fixed Reduction:schedule Day Morning Lunch Afternoon Night 1 20mg High Start 2 15mg Medium 3 Low Start 4 10mg 5 6 7

Very Severe Dependence Daily Alcohol Consumption Fixed Reduction: where to start Moderate Dependence Severe Dependence Very Severe Dependence Daily Alcohol Consumption 15-29 units 30-40 units 50-60 units SADQ Score 15-30 30-40 40-60 Detox Start Low Medium High

Fixed Reduction: additional notes PRN diazepam (5-20mg doses; max of 150mg total dose daily) – can be given at 2 hourly intervals but not usually given after first 48 hours. May need to alter timing of regular doses. Doses are not absolute and can be increased or decreased according to withdrawal severity Omit doses if patient drowsy

Front Loading / Symptom Triggered Therapy Aims To match pharmacotherapy to withdrawal symptoms To prevent kindling by (more-or-less) completely eradicating symptoms

STT: basic technique Patient assessed at appropriate intervals (90 mins) Standardised assessment tool used (CIWA-Ar) Those scoring above threshold given appropriate medication (20mg diazepam if scoring 11 or above)

STT: Diazepam Ideally suited because of pharmacokinetics Rapidly absorbed T1/2 diazepam = 33 +/- 11 hours T1/2 desmethyldiazepam = 50 hours Active metabolites present longer than the 72 hrs of AWS (Sellers et al, 1983)

STT: research Effective – good completion rates Studies have shown similar completion rates to other techniques (Wiseman et al, 1998)

STT: research Safe – no major complications 7 studies between 1983-1998 had no major complications (n=327) In one study minor complaints such as muscle weakness and drowsiness were described but no pt discontinued. In a comparison study, one pt in both STT and FR groups had DTs (Sellers et al, 1983; Heinala et al, 1990; Wartenburg et al, 1990; Saitz et al, 1994; Salloum et al, 1995; Wasilewski et al, 1996; Wiseman et al, 1998)

Lower doses of benzodiazepines used in total STT: research Lower doses of benzodiazepines used in total Chlordiazepoxide Satis et al, 1994 STT - 100mg FR - 425mg Study 1 Diazepam Wasilewski et al, 1996 STT - 40-210mg FR - 60-9480mg Study 2 Diazepam Day et al, 2004 STT - 74mg FR - 250mg Study 3

STT: research Shorter period of detoxification Wartenburg et al (1990) – 5 hours for STT cf 13 hours for FR Sullivan et al (1991) – the ‘typical’ patient requires only 2 – 3 doses of 20mg diazepam or 100mg CDP

STT: research STT can be used for home detox Currently used by Home Alcohol Detoxification Service in Torfaen (and in other areas) Has been shown to be safe and effective in this format (Blondell, 2005)

STT: cautions When to start? Other causes of autonomic and psychomotor agitation Clonidine and beta-blockers Sleep vs coma – once asleep continue to check at 90min intervals but check resp rate. Score once more upon waking.

Diazepam: too much? Death Respiratory Suppression Drowsiness Shakes Sweats Hallucinations Seizures Too much GABA Stimulation Too little GABA Stimulation

Nursing Reassurance can reduce need for diazepam Maintain calm environment Reduce level of stimulation Consistency of personnel Avoid carbohydrate load

Vitamin Prophylaxisis

Thiamine Co-enzyme in carbohydrate metabolism 2 routes absorption – active and passive Alcohol problems lead to poor diet Alcohol impairs active absorption Wernicke/ Korsakoff Withdrawal is time of increased risk

Glutamate overactivity Diet low in thiamine Chronic Drinking Withdrawal Glutamate overactivity Diet low in thiamine Poor absorption of thiamine Increased demand for energy Low body stores of thiamine Carbohydrate metabolism Brain damage Carbohydrate metabolism Limited repair Use of thiamine

Wernickes Encephalopathy Confusion Ophthalmoplegia (eye muscles not working properly) Nystagmus Truncal ataxia (unsteady gait) High index of suspicion – mortality rate 17-20% and 85% develop Korsakoffs

Korsakoff’s Psychosis Chronic memory loss (new memories) Apathy – can be profound Some loss of old memories – may stretch back many years Confabulation – fabrication of memories; generally displaced; may be fantastical Often orientated to place but take long time to adapt to new surroundings

Hepatic encephalopathy Central Pontine Myelinolysis All part of ARBD Brain Injury Vascular diseases Direct trauma Korsakoff’s Syndrome Also acute syndrome of Wernicke’s Neurological Syndromes Cerebellar atrophy Hepatic encephalopathy Central Pontine Myelinolysis Marchiofava Bignami Syndrome Alcohol Related Dementia Subcortical frontal disorders

Thiamine: part 2 Prophylaxis during withdrawal 2 amps daily for 5 days (im or iv) Treatment of Wernickes 2 amps bd Risk of anaphylaxis is small but real – resuscitation facilities required (1 report for every 5 million doses sold (CSM) – underestimate?)

Delirium Tremens Confusion, disorientation, agitation Autonomic instability (raised temp, HR, BP) Hallucinations (visual, tactile) Tremors Paranoia In 5-10% alcohol dependent patients Up to 5% mortality if treated; 35% if not

Using the CIWA-Ar Clinical Institute Withdrawal Assessment for Alcohol (revised) (Sullivan, 1991) Objective assessment of withdrawal Assess at 90 minute intervals Stop after two scores below 11

CIWA-Ar: Basic Information Name Date Time BP, HR, temp - don’t contribute to score but can give early signs of complications

CIWA-Ar: Nausea & Vomiting Score Indication No nausea and no vomiting No nausea and no vomiting 1 Mild nausea with no vomiting 2 3 4 Intermittent nausea with dry heaves 5 6 7 Constant nausea, frequent dry heaves and vomiting

CIWA-Ar: Tremor Score Indication No tremor 1 No tremor 1 Not visible, but can be felt fingertip to fingertip 2 3 4 Moderate, with patients arms extended 5 6 7 Severe, even with arms not extended

CIWA-Ar: Sweats Score Indication No sweat visible 1 No sweat visible 1 Barely perceptible sweating, palms moist 2 3 4 Beads of sweat obvious on forehead 5 6 7 Drenching sweats

CIWA-Ar: Anxiety Score Indication No anxiety, at ease 1 Mildly anxious No anxiety, at ease 1 Mildly anxious 2 3 4 Moderately anxious, or guarded, so anxiety is inferred 5 6 7 Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

CIWA-Ar: Agitation Score Indication Normal activity 1 Normal activity 1 Somewhat more than normal activity 2 3 4 Moderately fidgety and restless 5 6 7 Paces back and forth during most of the interview, or constantly thrashes out

CIWA-Ar: Tactile Disturbances Score Indication None 1 None 1 Very mild itching, pins & needles, burning or numbness 2 Mild itching, pins & needles, burning or numbness 3 Moderate itching, pins & needles, burning or numbness 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely hallucinations 7 Continuous hallucinations

CIWA-Ar: Auditory Disturbances Score Indication Not present 1 Not present 1 Very mild harshness or ability to frighten 2 Mild harshness or ability to frighten 3 Moderate harshness or ability to frighten 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely hallucinations 7 Continuous hallucinations

CIWA-Ar: Visual Disturbances Score Indication Not present 1 Not present 1 Very mild sensitivity 2 Mild sensitivity 3 Moderate sensitivity 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely hallucinations 7 Continuous hallucinations

CIWA-Ar: Headache Score Indication Not present 1 Very 2 Mild 3 Not present 1 Very 2 Mild 3 Moderate 4 Moderately 5 Severe 6 Very severe 7 Extremely severe

CIWA-Ar: Orientation Score Indication Orientated 1 Orientated 1 Cannot do serial additions or is uncertain about date 2 Disorientated for date by no more than 2 calendar days 3 Disorientated for date more than 2 calendar days 4 Disorientated for place/ or person

CIWA-Ar: Practice Time

Summary Symptom Triggered detox is safe and effective and helps prevent kindling Thiamine replacement is important The nursing component to withdrawal is probably the most important